The nurse plans care to prevent a dangerous thermal environment for an older adult client who lives in a northern climate of the United States. Which client assessment data does the nurse recognize that can contribute to the risk of hypothermia? (Select all that apply.)

Has a history of alcohol abuse

Bathes three to four times a week

Has a history of diabetes mellitus

Becomes diaphoretic on warm days

is prescribed antidepressant

Has a history of a cerebrovascular accident CVA

Answer and Explanation

Correct Answer : A,C,D,F

A. Has a history of alcohol abuse
Explanation: Alcohol can contribute to hypothermia as it causes vasodilation, leading to heat loss. It can impair the body's ability to regulate temperature.

B. Bathes three to four times a week
Explanation: While personal hygiene is important, the frequency of bathing alone may not be a direct risk factor for hypothermia. The overall environmental temperature and the individual's ability to regulate their body temperature are more critical considerations.

C. Has a history of diabetes mellitus
Explanation: Diabetes mellitus can increase the risk of hypothermia as it may affect circulation and peripheral nerve function. Impaired sensation and reduced blood flow can contribute to difficulty in maintaining body temperature.

D. Becomes diaphoretic on warm days
Explanation: Excessive sweating (diaphoresis) can contribute to the risk of hypothermia, as it leads to moisture loss from the skin, making it more challenging for the body to maintain a stable temperature.

E. Is prescribed antidepressant
Explanation: While certain medications, including some antidepressants, can affect thermoregulation, the prescription of an antidepressant alone does not necessarily indicate an increased risk of hypothermia. It is essential to consider the specific medication and its potential side effects.

F. Has a history of a cerebrovascular accident (CVA)
Explanation: Individuals with a history of a cerebrovascular accident may have impaired thermoregulation due to damage to the central nervous system. This can increase susceptibility to temperature extremes.

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Correct Answer is B

Explanation

A. "Side rails do not decrease falls, but they do decrease fall-related injuries."

Explanation: While side rails may reduce the severity of injuries if a fall occurs, they are not proven to decrease the overall rate of falls. Additionally, side rails themselves can pose risks, including entrapment.

B. There is no evidence that side rail use decreases falls, and in fact, there is a greater risk of injury."

Explanation: The use of side rails as a fall prevention measure has been associated with risks and has not been shown to effectively decrease the overall rate of falls. There is evidence that side rails can contribute to injuries, including entrapment, when patients attempt to climb over or through them. The focus in fall prevention has shifted towards individualized assessments, environmental modifications, and other strategies that address the specific needs and risks of each patient.

C. "Side rails are only effective when used with patients who have dementia."

Explanation: The effectiveness of side rails is not limited to patients with dementia. However, the use of side rails as a general fall prevention strategy has been questioned, and their use should be carefully considered based on individual assessments and risks.

D. "Side rails have only proven to be effective in decreasing falls in patients who have already fallen."

Explanation: The use of side rails is not universally proven to be effective in decreasing falls, even in patients who have previously fallen. The decision to use side rails should be based on a thorough assessment of the individual's needs and risks, considering alternatives to promote safety.

A. Comprehensive assessment B. Assessing for atypical presentation of Illness C. Complete blood count D. Differentiating delirium, dementia, and depression

Correct Answer is ["A","B","D"]

Explanation

A. Comprehensive assessment

Explanation: A comprehensive assessment involves a thorough evaluation of various cognitive functions, including memory, attention, language, problem-solving, and executive functions. This allows for a comprehensive understanding of an individual's cognitive abilities.

B. Assessing for atypical presentation of illness

Explanation: Assessing for atypical presentation of illness is relevant in a cognitive assessment because some medical conditions or illnesses can manifest with cognitive symptoms. Recognizing atypical presentations helps in identifying potential underlying causes of cognitive changes.

C. Complete blood count

Explanation: While laboratory tests like a complete blood count (CBC) may be useful in identifying certain medical conditions that could affect cognition, it is not a direct component of a cognitive assessment. Cognitive assessments typically involve clinical interviews, neuropsychological testing, and observation of cognitive functions. Blood tests and other diagnostic tools may be used to complement the cognitive assessment but are not considered components of it.

D. Differentiating delirium, dementia, and depression

Explanation: Distinguishing between delirium, dementia, and depression is crucial in a cognitive assessment. Each condition has distinct characteristics, and accurate differentiation is necessary for appropriate intervention and management.

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The nurse plans care to prevent a dangerous thermal environment for an older adult client who lives in a northern climate of the United States. Which client assessment data does the nurse recognize that can contribute to the risk of hypothermia? (Select all that apply.)

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

Components to a cognitive assessment include which of the following? (Select all that apply.)

Correct Answer is ["A","B","D"]

Explanation

A nurse conducts a comprehensive assessment of an older adult client. The nurse utilizes the Mini-Cog, a valid and reliable assessment tool to assess the individual's mental status. The nurse understands that the benefit of utilizing a standard assessment tool is what?

When assessing your client who has a history of falls, you should pay particular attention to which of the following? (Select all that apply.)

Which attempt by the family to prevent an older frail adult from falling causes the home health nurse concern?

In reviewing an older adult's insurance history, you find that he is on Medicaid. What do you know that Medicaid is used for?

Which attempt by the family to prevent an older frail adult from falling causes the home health nurse concern?

The nurse should encourage which of the following exercise(s) to assist with balance for a client who is at high risk for falls? (Select all that apply.

The health care provider has not ordered the use of a restraint for an alert patient at high risk for falling. The nurse should implement which side rail use?